In a recent meeting between the executive and (Republican) legislative branches, there is a renewed call to repeal the Affordable Care Act. What is a state to do that has to create a budget and does not know what the health care laws will be or even what federal funds might be available for helping provide care? Some states are not waiting around for repeal and replace but are taking matters in their own hands. New York, California, and Nevada may soon be on the way to single payer health systems. And if Republicans are true to their states rights roots, then letting states design and run their own systems should be a good thing.

The California plan is estimated to cost $400 billion a year, which would be paid for by a 15% payroll tax. The various California health programs already cost $367 billion meaning that the new plan should not cost more than current programs. The tax would be in lieu of premiums, deductibles and copays that people currently pay.

That California and New York would move in this direction probably surprises few people since these are traditionally progressive states. What is surprising is that the Nevada legislature passed a bill permitting anyone in the state to buy into Medicaid. This option would be a public health insurer for anyone in the state who lacks health insurance coverage. Under a Republican governor, this might be the first state to provide a “Medicaid for all” public health insurance program. The bill is sitting on the governor’s desk.

Beyond Nevada’s plan, there are not a lot of specifics on how these public insurance programs would operate, what they might cost, how they would be funded, what doctors and hospitals would be included, and what would happen to existing private companies and people who get insurance through their employers. Under the ACA, states can apply for waivers that permit them to experiment with insurance and delivery models while still receiving federal subsidies, so that might be a viable mechanism. Both the California and New York plans need to pass a second legislative house and be signed by their governors meaning that Nevada may be first in the nation with its program.

“Medicaid for all” was one of the planks of Bernie Sander’s presidential campaign. Given that the Congressional Budget Office predicts the proposed American Health Care Act would raise premiums (for those who are older and sicker), decrease Medicare rolls, and dramatically decrease coverage (including dropping about 23 million people from insurance), state officials are looking for solutions that will increase coverage and reduce cost.

Opponents of single-payer and universal coverage say that costs will spiral out of control, hospitals will fail, and the system will collapse. The same was said about the Affordable Care Act, the Clinton health plan, the Nixon health plan, Medicare, Medicaid, and even Social Security. Despite Republican propaganda, the ACA has been fairly successful.

The irony of this debate is that calls for repealing the Affordable Care Act may do more for bringing us to a universal health system, or at least a single-payer insurance system, than has been possible before.